Please tell us a bit about yourself so we can personalize the tools that can best help you in the process of becoming smoke-free.

This should only take you about 5 minutes.

1. Do you currently smoke cigarettes?
DailyOccasionally (if less than 7 days per week or less than 1 cigarette per day)

Not at all

2. When was your last cigarette?
Less than 24 hoursMore than 24 hours
3.
How many cigarettes do you or did you smoke on the days that you smoke?

4. At what age did you start smoking regularly?

5. What is your date of birth?

6. How soon after you wake up do you or did you have your first cigarette?
Within 5 minutes6-30 minutes31-60 minutesAfter 60 minutes
7. How many times have you tried to quit smoking where an attempt has lasted longer than 1 day?

8. How many members of your household smoke cigarettes?

9. You are:
MaleFemaleTransgender
10. About how much does/did a pack of cigarettes cost you?
[Example: 6.50]

Smokers' Helpline Online is for educational purposes only and is not to replace the advice of your family physician or other health care provider. SHO Version 6.0 is Copyright 2005 - 2015 by Evolution Health Systems Inc. All rights reserved including related methods and software. All worldwide patent rights reserved.